Obstetrical Nursing – Antepartum – NCLEX Quiz 2

1. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician?

Blood pressure reading is at the prenatal baseline

Urinary output has increased

The client complains of a headache and blurred vision

Dependent edema has resolved

If the client complains of a headache and blurred vision. the physician should be notified because these are signs of worsening Preeclampsia.

Explanation

If the client complains of a headache and blurred vision. the physician should be notified because these are signs of worsening Preeclampsia.

2. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education?

“I need to stay on the diabetic diet.”

“I will perform glucose monitoring at home.”

“I need to avoid exercise because of the negative effects of insulin production.”

“I need to be aware of any infections and report signs of infection immediately to my health care provider.”

Exercise is safe for the client with gestational diabetes and is helpful in lowering the blood glucose level.

Explanation

Exercise is safe for the client with gestational diabetes and is helpful in lowering the blood glucose level.

3. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)?

Elevated blood pressure

Negative urinary protein

Facial edema

Increased respirations

The three classic signs of preeclampsia are hypertension. generalized edema. and proteinuria. Increased respirations are not a sign of preeclampsia.

Explanation

The three classic signs of preeclampsia are hypertension. generalized edema. and proteinuria. Increased respirations are not a sign of preeclampsia.

4. A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and is awakened by the cramps at night. To provide relief from the leg cramps. the nurse tells the client to:

Dorsiflex the foot while extending the knee when the cramps occur

Dorsiflex the foot while flexing the knee when the cramps occur

Plantar flex the foot while flexing the knee when the cramps occur

Plantar flex the foot while extending the knee when the cramps occur.

Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle. prevents the muscle from contracting. and stops the cramping.

Explanation

Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle. prevents the muscle from contracting. and stops the cramping.

5. A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions?

“I need to cook meat thoroughly.”

“I need to avoid touching mucous membranes of the mouth or eyes while handling raw meat.”

“I need to drink unpasteurized milk only.”

“I need to avoid contact with materials that are possibly contaminated with cat feces.”

All pregnant women should be advised to do the following to prevent the development of toxoplasmosis.Options A and B: Women should be instructed to cook meats thoroughly. avoid touching mucous membranes and eyes while handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption.Option D: Avoid contact with materials that possibly are contaminated with cat feces. such as cat litter boxes. sandboxes. and garden soil.

Explanation

All pregnant women should be advised to do the following to prevent the development of toxoplasmosis.Options A and B: Women should be instructed to cook meats thoroughly. avoid touching mucous membranes and eyes while handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption.Option D: Avoid contact with materials that possibly are contaminated with cat feces. such as cat litter boxes. sandboxes. and garden soil.

6. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to:

Avoid wearing a bra

Wash the nipples and areola area daily with soap. and massage the breasts with lotion.

Wear tight-fitting blouses or dresses to provide support

Wash the breasts with warm water and keep them dry

The pregnant woman should be instructed to wash the breasts with warm water and keep them dry.Option A: Wearing a supportive bra with wide adjustable straps can decrease breast tenderness.Option B: The woman should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues.Option C: Tight-fitting blouses or dresses will cause discomfort.

Explanation

The pregnant woman should be instructed to wash the breasts with warm water and keep them dry.Option A: Wearing a supportive bra with wide adjustable straps can decrease breast tenderness.Option B: The woman should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues.Option C: Tight-fitting blouses or dresses will cause discomfort.

7. A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse?

Urinary output of 20 ml since the previous assessment

Deep tendon reflexes of 2+

Respiratory rate of 10 BPM

Fetal heart rate of 120 BPM

Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute. the physician or other health care provider needs to be notified. and continuation of the medication needs to be reassessed. Option A: A urinary output of 20 ml in a 30 minute period is adequate;;;

Explanation

Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute. the physician or other health care provider needs to be notified. and continuation of the medication needs to be reassessed. Option A: A urinary output of 20 ml in a 30 minute period is adequate;;;

8. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for:

Any bleeding. such as in the gums. petechiae. and purpura.

Enlargement of the breasts

Periods of fetal movement followed by quiet periods

Complaints of feeling hot when the room is cool

Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.

Explanation

Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.

9. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected. and the nurse instructs the client regarding management of care. Which statement. if made by the client. indicates a need for further education?

“I will maintain strict bedrest throughout the remainder of the pregnancy.”

“I will avoid sexual intercourse until the bleeding has stopped. and for 2 weeks following the last evidence of bleeding.”

“I will watch for the evidence of the passage of tissue.”

Strict bed rest throughout the remainder of pregnancy is not required.Option B: The woman is advised to curtail sexual activities until the bleeding has ceased. and for 2 weeks following the last evidence of bleeding or as recommended by the physician.Option C: The woman is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad.Option D: The woman also should watch for the evidence of the passage of tissue.

Explanation

Strict bed rest throughout the remainder of pregnancy is not required.Option B: The woman is advised to curtail sexual activities until the bleeding has ceased. and for 2 weeks following the last evidence of bleeding or as recommended by the physician.Option C: The woman is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad.Option D: The woman also should watch for the evidence of the passage of tissue.

10. A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia. the nurse's first action is to:

Administer magnesium sulfate intravenously

Assess the blood pressure and fetal heart rate

Clean and maintain an open airway

Administer oxygen by face mask

The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.

Explanation

The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.